Appendix (7) to Medical Management and Disease Prevention Manual, Rev. 4 (E) 26 March 2009

MEDICAL EXAMINATION for EMPLOYMENT

INSTRUCTIONS TO THE CREW MEMBER

Dear Crew Member,

You are required to have a valid Medical Examination before joining your Crystal Cruises ship. Take time to read this instruction before going for your medical examination.

1. Take the Medical Examination Report to the doctor or clinic that has been recommended by your agent or ICMA.

Alternatively, visit your licensed private physician only if agreed to with ICMA.

2. Attach a passport size photo to page 6, Medical Certificate.

3. Fill in the self declaration on pages 7 and 8 and sign it.

4. Fill in the self declaration “Back and Spine” on page 11 and sign it.

5. Fill in the self declaration “Infectious Disease Immunity Verification” on page 12 together with the Examining Doctor.

6. The doctor shall fill in all other information on pages 6, 7, 9 and 10.

7. When all of the test results are determined, the doctor shall complete page 6, stating whether you do/do not meet the medical requirements. The doctor shall also sign page 6 and affix his/her official stamp.

8. Once all of the pages (6 through 12) are completed, you need to forward all 7 pages and all lab tests to ICMA

before you will be permitted to travel to your ship. You can forward them as follows:

- Scan / email to medical@icma.no

- Telefax to +47 2335 7901

9. ICMA will contact you with your travel instructions once our Company Medical Advisor has approved your medical examination.

10. Bring your copy of the Medical Examination with you to the ship.

Thank you for carefully following these instructions. By doing so, you will help us to get you onboard your ship in the most timely manner, with your medical documentation in order. If you have any questions, do not

hesitate to contact your Personnel Consultant at ICMA.

Kind regards,

The ICMA Team

November 2008

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Appendix (7) to Medical Management and Disease Prevention Manual, Rev. 4 (E) 26 March 2009

MEDICAL EXAMINATION for EMPLOYMENT

INSTRUCTIONS TO THE DOCTOR

Dear Doctor,

The seafarer you are about to examine is seeking work onboard a cruise vessel operated by Crystal Cruises. Attached you will find a Medical Certificate and a Medical Examination Report that you need

to complete. Please note the following important details:

Medical Certificate

The medical certificate is valid for a period of two years.

Ensure that all information for the seafarer is completely filled in, including the ID

(Passport and/or Discharge Book) number on page 6.

Ensure that the attached photograph is the person to be examined. Place your official

stamp partially on the photograph and the document.

Upon completion of the medical examination, be sure to complete all details about your

name, clinic or hospital, and address. Affix your stamp to the Medical Certificate (page 6).

Medical Examination Report

Ensure that the seafarer has completed all voluntary information correctly (pages 7, 8

and 11).

Verify the MMR information on page 12 together with the seafarer, and sign when

completed.

Verify the Personal Medical History information carefully with them. You need to sign as a

witness on page 8.

Please note that no vaccinations are required or authorized, unless specifically requested

by the Employer. See page 7.

Conduct the complete Medical Examination and Summary on pages 9 and 10.

We ask you to specifically check the seafarer’s back and spine for signs of injury or

weakness. Any skeletal weaknesses or injuries will disqualify the seafarer from

employment with us.

We ask you to be thorough and honest in your evaluation of the seafarer.

It is very important that all test results are determined before the Medical Certificate is

completed. Please attach the analysis reports to the Medical Examination Report.

Carefully read the attached Medical Guidelines for Hiring Crystal Shipboard

Personnel.

Thank you for your kind attention to this important medical examination for employment at sea.

Sincerely,

Thomas Carlson General Manager International Cruise Management Agency AS Jernbanetorget 4B, 0154 Oslo, Norway medical@icma.no

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Appendix (7) to Medical Management and Disease Prevention Manual, Rev. 4 (E) 26 March 2009

MEDICAL GUIDELINES FOR HIRING CRYSTAL SHIPBOARD PERSONNEL

The employment physical examination should establish that the applicant does not have any mental or

physical disability or disease that interferes with his or her daily work or may in any way endanger the

health of other persons onboard. It should also ensure that the applicant’s visual acuity, color vision and

hearing fulfill the international regulation requirements for his or her type of work onboard.

GENERAL DISQUALIFYING CONDITIONS (NOT FIT FOR SEAGOING EMPLOYMENT)

Any mental, physical or medical condition that may interfere with the ability to function

effectively in daily work onboard, in any emergency, or in any drill.

Conditions that may endanger life or health of others onboard.

Visual ability or hearing poorer than the international regulation requirements. (See page below)

Conditions that require regular medical follow-up or medication.*

Medical conditions that harbor risk of flare-ups or complications necessitating emergency

evacuation from the ship.

SPECIFIC DISQUALIFYING CONDITIONS (NOT FIT FOR SEAGOING EMPLOYMENT)

1. Communicable diseases, including venereal disease

Venereal disease until adequately treated

Active or incompletely treated tuberculosis

Persons with radiological signs of pulmonary tuberculosis where previous treatment history

cannot be verified.

2. Malignant neoplastic disease

3. Endocrine disease

Diabetes mellitus Type I insulin dependent

Diabetes mellitus Type II unstable *

4. Mental and psychological diseases

Psychoses and severe depression requiring active psychotic drugs

Neurotic disorders needing treatment and requiring the use of psychotropic drugs

Behavioral disturbances, obvious adaptation difficulties

Enuresis

Alcoholism

Drug addiction or abuse

History of illicit drug use

Any regular use of psychotropic drugs

History of psychosis

5. Neurological disease

Symptomatic neurologic disorders

Epilepsy

Severe migraine headaches

Neuralgias

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Appendix (7) to Medical Management and Disease Prevention Manual, Rev. 4 (E) 26 March 2009

6. Cardiac disease

Symptomatic or functionally significant heart disease

Peripheral vascular disease

Hypertension (individual assessment)*

Conditions requiring continuous anticoagulant therapy

7. Respiratory disease

Chronic bronchial conditions

Asthma requiring treatment

8. GI disease

Disease of the teeth and gums until adequately treated

Recurring dyspepsia with or without ulcer

Symptom-giving gallstones

Chronic diseases of liver or pancreas

Chronic enteritis or colitis

Hernia (untreated or unsuccessfully treated).

9. GU disease

Present calculi (stones) of urinary tract

Chronic nephritis or nephrosis

Prostatitis

10. Gynecological disease and conditions

Recurring salpingitis

Irregular menses (periods) with heavy blood loss

Pregnancy

11. Dermatological disease

Contagious skin diseases until adequately treated

Severe skin diseases

Allergies to substances commonly onboard (e.g. metals, petroleum products, detergents)

12. Musculoskeletal disease

Recurring or chronic back pain with significant disability

All musculoskeletal diseases, congenital malformations and sequelae after injuries which will

interfere with the ability to function effectively in an emergency or drill.

13. Long term medications

Person needing long term medication for reasons not mentioned above (e.g. transplant recipients). *

* Persons with these conditions might be approved by CCI’s Medical Consultant after his careful

evaluation of the individual’s history, symptoms and your objective findings. Examining physicians

should mark the Medical Certificate “DOES NOT meet physical requirements” and describe the

reason and notify ICMA who will arrange for further evaluation.

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Appendix (7) to Medical Management and Disease Prevention Manual, Rev. 4 (E) 26 March 2009

Standards for Visual Acuity, Color Vision and Hearing

Minimum Standards (Ref: UK MSN 1765 (M) Appendix 1 to Annex B)

Crew Position Vision

(distance)

Visual Field Color

(Ishihara)

Hearing

(USCG Std.)

Captain

Vice Captain

1st Officer

2nd Officer

Boatswain

Carpenter

Quartermaster

Able Seaman

Ordinary Seaman

Sailor

Unaided:

Both Eyes: 6/60

Aided:

Better Eye: 6/6

Other Eye: 6/12

Near Vision: N8

Normal – No

pathological

field defect

Normal Unaided:

Threshold 70

db or less each

ear. 90%

speech

discrimination

Chief Engineer

Asst. Chief Engineer

Electrical Engineers

Electronic Engineers

Refrigeration

Engineers

1st Engineer

2nd Engineer

3rd Engineer

Marine Storekeeper

Oiler

Wiper

Unaided: 6/60

Aided:

Better Eye: 6/18

Other Eye: 6/18

Near Vision: N8

Sufficient for

duties

Normal Unaided:

Threshold 70

db or less each

ear. 90%

speech

discrimination.

ALL Other Positions Sufficient to undertake duties efficiently

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Appendix (7) to Medical Management and Disease Prevention Manual, Rev. 4 (E) 26 March 2009

MEDICAL CERTIFICATE

Photo

Last Name First and Other Names Position applied for

Date of Birth

Sex

Nationality ID (Passport/Discharge book) No:

DD MM YYYY

Ship Name

I have evaluated the above-named examinee according to the ICMA Medical Guidelines (Based on UK Medical Requirements for Seafarers MSN1765(M), and on the basis of the examinee’s personal declaration, my clinical examination, and the diagnostic test results obtained, and in consideration of the essential requirements of the position applied for, in my opinion this employee DOES / DOES NOT meet the physical requirement for this job.

(circle one) Restrictions applied: None/…………………………………………………… If unfit state reason Visual aid required (specify) Yes/No Informed spares necessary Yes/No Fit for lookout duty Yes/No

Signed: Name: Clinic stamp: Date: I acknowledge that I have been advised of the content of the medical examination form. Crew Member’s signature:

A copy of this page should be kept by the examining physician, and a copy sent to the ICMA. The entire original medical examination form should be given to the seafarer.

DD YYYY MM

Photo

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Appendix (7) to Medical Management and Disease Prevention Manual, Rev. 4 (E) 26 March 2009

MEDICAL EXAMINATION REPORT - STRICTLY CONFIDENTIAL This examination must be carried out by an authorized physician. The seafarer must meet the minimum standards set down by the authorizing body. Reference should also be made to the guidelines included.

Last name First and Other Names

Date of Birth

Sex

Position/Job Applied For

DD MM YYYY

Home Address

Usual Medical Practitioner – Name/Address

Date/result of last medical examination: Date/result of last Employment Physical Exam (if any): DD MM YYYY

EMPLOYMENT PHYSICAL EXAM QUESTIONNAIRE - PERSONAL MEDICAL HISTORY To be completed by the Crew Member and given to the Examining Physician.

Vaccination status (This section is for information only. No vaccinations are required/authorised as part of this exam) State date of last vaccination/immunity (if not vaccinated, state N/A next to the item): Diphtheria: Tetanus: Pertussis: Polio: Hepatitis A: Typhoid : Hepatitis B: Yellow Fever: MMR: Varicella:

To the best of your knowledge, have any of your family ever suffered from any of the following? Heart conditions/angina, Blood pressure problems, Stroke/vascular disease, Mental/nervous, disorder, Diabetes, Tuberculosis, Asthma/eczema, Glaucoma, Epilepsy/fits, Cancer, Anaemia If yes, please give details:

Are you taking any non-prescription or prescription medications? Yes/No Please list with dosage, and reason for taking ___________________________________________________________________ Have you any allergies to medications, or to environmental allergens eg Hay Fever? Yes/No Do you smoke? Yes/No Number of cigarettes per day Do you drink alcohol? Yes/No Number of units per week Do you feel healthy and fit to perform the duties of your designated position/occupation? Yes/No Have you ever been declared unfit for sea duty, or had your medical certificate restricted or revoked? Yes/No

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Appendix (7) to Medical Management and Disease Prevention Manual, Rev. 4 (E) 26 March 2009

EMPLOYMENT PHYSICAL EXAM QUESTIONNAIRE - PERSONAL MEDICAL HISTORY To be completed by the Crew Member and given to the Examining Physician.

Have you ever had any medical conditions affecting the systems below? Y N If yes, give details:

Eye or vision problem: Glaucoma, Eye injury, Glasses/ contact lenses

Dental problems

Ear/nose/throat problems: Ear Infections, Hearing Problems, Sinus Trouble, Recurrent Nose Bleeding

Heart problems: Rheumatic Fever, abnormal heart beat, Chest Pain, Heart Attack, Heart surgery

Vascular disease: High blood pressure, Varicose veins, Poor Circulation

Chest problems: Shortness of Breath, Coughing up Blood, Asthma/bronchitis, Wheezing, Pneumonia, Pleurisy, TB

Endocrine or hormone disorders: Diabetes or blood sugar problems, Thyroid problem

Malignant Diseases: Cancer or Tumour, Blood disorders

Kidney problems: Urinary Infections, Blood in Urine, Kidney Stones

Genital disorders: Sexually Transmitted Disease

Males: Prostate Disease, Testicular lumps or swellings, Varicocele

Females: Gynae problems, abnormal smears, painful periods, pregnancy problems, Breast lumps

Date of last menstrual period: (exclude Pregnancy)

Skin problems: Dermatitis, Rashes, Exzema, Psoriasis

Infectious/contagious diseases: Malaria or other tropical diseases, HIV / AIDS

Digestive disorder: Frequent Indigestion, Gastric/Duodenal Ulcer, Abdominal Pain Diarrhoea, Constipation, Bleeding from gut, Jaundice, hepatitis or Liver Complaints, Hernia, Haemorrhoids/piles

Neurological problems: Epilepsy, seizures or Blackouts, Dizziness/fainting, Loss of consciousness, Frequent Severe headaches or Migraines, Muscular Weakness or Paralysis, Tingling or Numbness, Balance problems, Stroke, Head Injury or Concussion, loss of memory

Psychiatric problems: Anxiety, Depression, Sleep problems, Nervous Breakdown, suicide attempt

Restricted mobility: Back problems, Sciatica, Fractures, Dislocations, Severe Sprain, Arthritis, Rheumatism, Joint pain

Apart from conditions as above, have you had any other operations or surgery, serious accidents or injuries, medical problems, diseases or illnesses, visits to health care professionals or hospital admissions? Yes/No -------------------------------------------------------------------------------------------------------------------------------------------------------------- I certify that the above medical information is true and any false information provided will be grounds for immediate dismissal. Any failure to disclose any pre-existing medical condition will be grounds to exclude claims for any illness/injury and other benefits to which I might otherwise be entitled. The details of my medical examination may be released to my own doctor and also the results may be communicated to the personnel department of the company/UK Club for whom this examination is carried out. I hereby authorize the release of all my previous medical records from any health professionals, health institutions and public authorities to this Examining Physician.

______________________ ___________________________ Signed: (Applicant) Examining Physician Date DD YYYY MM

M

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Appendix (7) to Medical Management and Disease Prevention Manual, Rev. 4 (E) 26 March 2009

EMPLOYMENT PHYSICAL EXAMINATION To be completed by the Examining Physician.

Height (cm) Weight (kg) BMI (kg/m2) Rate Rhythm Systolic Diastolic

Pulse Blood Pressure

Ishihara Normal/Abnormal

Visual fields Normal/Abnormal

Glucose Protein

Blood

Lung Function

PEFR FEV1 FVC

Urinalysis (+/-)

Systems examination

Normal/Abnormal (give detail) Normal/Abnormal (give detail)

General appearance Vascular (inc. pedal pulses)

Eyes, pupils Varicose veins

External Ocular Movements

Abdomen, inc Hernial orifices

Opthalmoscopy Genito-urinary(Not Pelvic Exam)

Ear, inc Tympanic Membrane

Anus, (Not Rectal Exam)

Nose Musculo-skeletal

Throat Spine – Cervical, thoracic and lumbar

Mouth, Teeth, speech CNS – inc general neuro exam

Breast examination Lymphatic system

Chest and lungs Skin

Heart Mental capacity

Vision Distance (Snellen chart)

Unaided R 6/ L 6/ Both 6/

Aided R 6/ L 6/ Both 6/

Near (Sloan letters)

Unaided R N L N Both N

Aided R N L N Both N

Audiogram right ear

Khz 500 1,000 2,000 4,000 6,000 8,000

dB

left ear

Khz 500 1,000 2,000 4,000 6,000 8,000

dB

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Appendix (7) to Medical Management and Disease Prevention Manual, Rev. 4 (E) 26 March 2009

Test Results*

See guidelines for requirements for each test

State whether applicable, Positive/Negative, Normal, or if abnormal give details

Chest X-Ray (on initial employment and every

subsequent physical)

Electrocardiogram (only for individuals age 50

and above unless extenuating circumstances require

it).

Full Blood Count

Urea, electrolytes, Creatinine, Glucose, LFTs

Hepatitis A

Hepatitis B – HBsAg, if positive other markers to establish infectivity

Hepatitis C – anti HCV

Syphilis serology VDRL/RPR

Other:

Other:

*Examining physician to attach lab test reports and x-ray reports separately.

Based on the examination results above, I find this individual to be (circle one): Fit / Temporarily unfit / Permanently unfit Name of Doctor: Signature of Doctor:

Date of Examination: DD MM YYYY

Name of examining Clinic/Hospital:

Clinic Stamp:

The original of pages 6 to 12 should be given to the seafarer, a copy kept by the Examining Physician, and a copy sent to ICMA.

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Appendix (7) to Medical Management and Disease Prevention Manual, Rev. 4 (E) 26 March 2009

Self-declaration – Back and Spine

It is mandatory for all applicants to complete this form. False statements may lead to termination of employment.

Name: D.O.B.

Have you ever suffered from back pain in the past? (Circle one) Yes No

If yes,

1. When? (List year. If more than once, list all years)

2. What symptoms and signs did you have? (Please circle appropriate response)

a. Pain all over? Yes No

b. Low or high back pain? Yes No

c. Pain also when resting? Yes No

d. Pain radiating to buttocks, legs or arms? Yes No

e. Other (please specify)

3. What kind of investigations did you go through: (Please circle appropriate response)

a. Examination by general practitioner or seaman’s doctor. Yes No

If yes, who? Name, Address and Date of exam

b. Examination by specialist? Yes No

If yes, what type of specialist? Name, Address and Date of exam

c. Examination by other health professionals Yes No

If yes, please indicate type (chiropractor, physiotherapist, masseur, other)

d. X-rays of back/spine Yes No

e. Ultra sound/sonogram, Bone Scan, MRI or CT Yes No

If yes, Type of exam? Name, Address and Date of exam

4. What was the diagnosis (i.e. what were you told was wrong with your back?)

5. What do you think was the cause:

a. Overwork / Over-exertion? Yes No c. Infection? Yes No

b. Acute injury? Yes No d. Other

6. Did you receive any kind of treatment? Yes No

If Yes, what kind of treatment?

a. Medicine No Yes If yes. What type and how long?

b. Massage No Yes

c. Physiotherapy No Yes If yes. What type and how long?

e. Chiropractic No Yes If yes. What type and how long?

f. Surgery No Yes If yes. What type?

7. Did your back pain lead to:

a. Sick leave from work

b. Medical Sign-Off No Yes If yes, how long?

c. Disability pay No Yes If yes, where? When?

8. How are you now? (Check one)

Fully recovered

Recovered, but must be careful with certain types of action

State types:

Still suffer from back pain (Describe)

Name (print) Signature Date

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Appendix (7) to Medical Management and Disease Prevention Manual, Rev. 4 (E) 26 March 2009

INFECTIOUS DISEASE IMMUNITY VERIFICATION

To be completed by crew member:

Last name: _______________________________ First name: _______________________________ Date of Birth: _______________________________ DD MM YYYY IMPORTANT NOTE FOR COMPLETING THIS FORM: LIST THE DISEASE IMMUNITY BY PROVIDING THE DATES OF:

THE DATES THAT YOU EXPERIENCED THE DISEASE (Varicella ONLY) or THE DATES THAT YOU WERE IMMUNIZED (VACCINATED) or THE DATES OF POSITIVE IMMUNITY BY TITER

If you have been immunized or have positive immunity by Titer, you must present immunization records or titer results to the physician conducting your exam for verification. PREVIOUS IMMUNIZATION OR POSITIVE TITER IS ACCEPTABLE PROOF OF DISEASE IMMUNITY. A PAST HISTORY OF DISEASE IS ACCEPTABLE ONLY FOR VARICELLA.

MUMPS, MEASLES & RUBELLA IMMUNITY VERIFICATION IS REQUIRED FOR ALL CREW!

Disease Date: Immunization Date:

Positive Disease Titer:

Record Verified (To be completed by Physician. Check as appropriate))

Mumps

or DD MM YYYY or DD MM YYYY Y N

Measles

or DD MM YYYY or DD MM YYYY Y N

Rubella

or DD MM YYYY or DD MM YYYY Y N

Varicella (Chicken Pox) DD MM YYYY or DD MM YYYY or DD MM YYYY

Y N

Signature of Completion and Accuracy: ` I certify that the above named person has presented me with records which indicate active immunity against each of the diseases above: ______________________ _______________________ _________________ Name of Clinic or Physician Signature of Physician Date DD MM YYYY (Official Stamp) All employees reporting onboard must provide proof of vaccination against Rubella and Varicella. If proof cannot be provided, the crew member will be required to be vaccinated onboard against these diseases. If the crew member refuses to be vaccinated onboard, he/she will be sent home at their own expense and not rehired!